While evidence-based guidelines are fine-tuning a safe, effective approach to acute migraine care, it appears many younger patients are not receiving the care they need for their migraine attacks.

Nearly half of pediatric patients did not receive any treatment for their migraines, and a vast majority of children did not receive evidence-based prescriptions or recommendations, according to the results of a multi-state retrospective study.1

“This is not just a pediatric problem, we actually know from a number studies over the last 20 years that headache is an underdiagnosed condition,” Robert A. Nicholson, PhD, LCP, FAHS, from the Mercy Clinic Headache Center & Mercy Health Research in St. Louis, Missouri, told Practical Pain Management.

When a patient presents with migraine, evidence-based guidelines typically recommend some form of abortive treatment, such as triptans or nonsteroidal anti-inflammatory drugs (NSAID).2 However, many patients do not receive any of these treatments,3 and this appears to be the case for younger patients as well.

“This study does point out that, for adults and children, migraine and headache tends to be undertreated. The fact that many patients, young and older, are sent home with no specific migraine treatment is discouraging, but not surprising,” said Lawrence Robbins, MD, a headache specialist practicing in Riverbrooks, Illinois.

The Study

Using data from Epic Electronic Health Records, the retrospective, observational study looked at 38,926 patients presenting at 1,617 centers across 4 states. Dr. Nicholson and colleagues found that 46% (n=17,911) of the patients did not receive any prescription or recommendations for their condition, while 84% (n=32,659) were not treated according to evidence-based guidelines.

Girls appeared more likely to receive evidence-based treatments for their migraines (OR= 1.14, 95% CI = 1.07-1.21, P < 0.001) compared to boys. In general, patients were much more likely to receive treatment if they were diagnosed with a migraine, rather than undiagnosed (OR = 4.71, 95% CI 4.17-5.33, P < 0.001).

Patient Demographics

Female (57%)

Caucasian (78%)

Mean age – 12.08 years (+/- 3.46)

Diagnosis Rate

Diagnosed with migraine (18%)

Diagnosed with headache (37%)

Not formally diagnosed (46%)

The argument could be made that not every patient required a prescription or over-the-counter (OTC) drug for his or her condition. However, evidence-based guidelines include nonpharmacological therapies for the acute and prophylactic management of migraine.4,5 It may have been possible some patients received more substantial care after a second visit, but “it shouldn’t take someone having to come back and be incredibly persistent to get good care,” Dr. Nicholson noted.

Undertreatment in the ED?

“We discovered that the best care occurs for children diagnosed with migraine who are treated in a primary care setting.” By contrast, younger patients were less likely to receive medication when they went to an ED (OR= 0.78, 95% CI = 0.67-0.91, P < 0.001), something that may be attributable to the nature of emergency care itself, Dr. Nicholson explained.

“You can envision a scenario where a well-intentioned, well-meaning doctor may not take the migraine necessarily seriously, especially if they’re trying to think about the child in general.” A patient presenting with cardiac arrest may garner more attention from an ED physician than a child with a severe headache. Plus, if a child is very young, poor communication of symptoms can be a significant barrier.

Also, health care providers located in metropolitan regions were less likely to prescribe evidence-based medicine (OR = 0.65, 95% CI = 0.58-0.74, P < 0.001). Given the vast majority of patients did not receive evidence-based care, it seems like many physicians are not up-to-date with guideline protocols for treating migraine.

Access to Education/Guidelines

Headache education of physicians (and other health providers) “has gone downhill over the last 10 years,” said Dr. Robbins. “The primary reason is that pharmaceutical companies drove much of the excellent headache education. From 1995 to 2005, there were many Grand Rounds, resident talks, and dinner lectures on headache, mostly fueled by the pharmaceutical industry. Since that time, the main ‘triptan’ migraine drugs have gone off patent, and companies halted promotion [including grants for educational programs].”

The headache organizations, particularly the American Headache Society, have continued to promote headache education. “Unfortunately, it is much more difficult to educate the residents in this environment. The current neurology residents are not as informed about headache as they were when we had many headache programs. I expect this to change, but the level of headache knowledge among our younger physicians is less than ideal,” Dr. Robbins told Practical Pain Management.

“I don’t think people are dropping the ball consciously,” said Dr. Nicholson. Practicing physicians are bombarded with new information every year, which is why medical schools are starting to make a concerted effort to incorporate high-quality headache training for students still in training.

This change will better prepare providers to be better positioned to provide the best care for their patients when they present with migraine, headache, and other head pain symptoms, noted Dr. Nicholson.

While there is still a paucity of controlled studies about migraine pharmacotherapy for the pediatric population,6 headache specialists already are developing successful protocols for treating children with migraine, specifically in the ED setting.7,8

“We know which medications work best in children and teens with migraine,” said Dr. Nicholson. “It’s time that healthcare providers understand that evidence-based care is the right way to go.”

The study was presented as part of this year’s annual meeting of the American Headache Society, held last June in Washington, DC. The authors of this study reported no relevant conflicts of interest. To view the AHS’s treatment guidelines for migraine diagnosis and treatment in children, click here.

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